/Making a difference on a medical student's schedule

As I post this, it’s a month shy of my third year blogging anniversary. When I first started, it was half a prayer for myself to start writing again and half a dream that I might create something worth remembering during medical school. I’ve neither managed to write consistently, nor create something truly remarkable, but I have learned so much from the experience of putting myself into the public eye and committing to making my opinions known.

So I’m writing today to thank you my readers for being with me on this journey, and also to ask those of you that have been following me on Google Reader to continue doing so using some other RSS reader picking up the slack, like Feedly or Newsblur, or even subscribing to my feed via email (I promise not to spam. All that goes through the email right now is new posts anyways).

I write also to ask — who are you, dear readers? and what brings you here? what would bring you back?

I’m learning that more than anything, the social web is a far better listening platform than anything else. I’m learning more than anything that even if you feel underqualified and unready, it’s better still to put yourself forward than to hold yourself back.

More posts soon as third year wraps up in four (!!!) more days. Thank you again, so much, for being here.

Like every other health policy nerd out there, I’ve been following the debate over the Oregon Medicaid experiment results about as closely as most Chicagoans followed the Bulls game. For those not up to speed, here’s a quick replay:

Due to financial constraints, Oregon was only able to expand Medicaid enrollment by 10K in 2008, though many more people were eligible to enroll, so they only allowed people to enroll by lottery.

Social scientists quickly realized that this was the ideal “randomized controlled trial” of Medicaid (or any health insurance) anywhere, and started tracking the outcomes of the 10K that won the lottery and some of those that did not.

The results of the study, most simply put by the study itself, are that the study authors:

found no significant effect of Medicaid coverage on the prevalence or diagnosis of hypertension or high cholesterol levels or on the use of medication for these conditions. Medicaid coverage significantly increased the probability of a diagnosis of diabetes and the use of diabetes medication, but we observed no significant effect on average glycated hemoglobin levels or on the percentage of participants with levels of 6.5% or higher. Medicaid coverage decreased the probability of a positive screening for depression (−9.15%; p=0.02), increased the use of many preventive services, and nearly eliminated catastrophic out-of-pocket medical expenditures.

As others have already bloggedextensively, there are a very good mathematical reasons for why the study was not able to achieve statistical significance, even when many of their desired outcomes did move in the direction they were hoping. Mainly, the study was underpowered (i.e. did not have enough people to achieve statistical significance), particularly since the experimental group ended up being relatively healthy (Only about 7% had hypertension and only about 5% had diabetes!) — not to mention the numerous other limitations revealed when one looks at the details of the study design in the appendix.

Other writers, especially physicians, have simply thrown up their hands and said, ‘look, we never said that health care insurance was anything more than a first step towards better health care for all.’ It reduces the financial burden of health care and prevents catastrophic out-of-pocket medical expenditures. It increases access to preventive services and starts people on the necessary medications for chronic conditions like diabetes — what else could you expect from just providing health insurance, when we haven’t yet solved the puzzle of health care quality or health care coordination?

I love the world of health services research, and respect all the commentators I’m linking to here, but I can’t help feeling like all this policy wonkish internal baseball is missing the point. How am I supposed to explain this to my patients or my friends that aren’t also social scientists? Am I supposed to go into how this highly limited study with gold standard methodology came up with this really convoluted result and what that (doesn’t) mean?

I know that how my patients respond to my words is about much more than me. It's about the experiences that they have had with their health, their family/friends' health and the health care system. But I still did not expect as vehement a response as I got to the word “hospice.”

She had been very polite, welcoming us into her home to talk about end-of-life care. She was remarkably well-informed, which did not surprise me (I've always suspected that people who volunteer to talk to medical students are likely self-selected to be more health-savvy and well-educated). But when I said this word, “hospice,” which for most people implies relief and repose and a way to get help when the struggles of caregiving become too much, she dismissed it immediately.

When she told me about her experience, I appreciated that she had not dismissed me.

She’s obese. She smokes. She has chronic disease. She’s pregnant. You ask her to get out of bed the day after surgery, telling her that yes, you know that it hurts and she is uncomfortable and overwhelmed, but if she doesn’t she it at risk for worse outcomes, blood clots and other terrible things. You ask her to quit smoking because it is not only good for her, but good for her baby. She says no, she can’t. She won’t.

Any health care provider reading this will tell you that they talk to these patients all the time. We have words we use to describe them. “Noncompliant” chief among them, along with many others that all come down to our sense that she is not really understanding of her condition. We talk on rounds about how the connections that seem so logical to us are not connecting for her. We apologize to each other for handing off this “difficult” patient to one another. We shrug and let her stay in the hospital a few more days, for “education” and “physical therapy,” hoping that maybe tomorrow she will understand that she can get out of bed, walk down the hall with her babies and out of our hospital.

We — the greater we, the people concerned about healthcare as a field and an industry and a neverending sink on our national economy — talk about this patient as well sometimes. We wonder what a role she might have in increasing our healthcare costs. We are concerned that in many ways, the many regulations we have pushed through in health care reform are never going to touch people like her. For all our talk of wanting to fund patient education, health literacy and primary care, we still know that these “soft” public health measures will and are on the chopping block when funds are tight. So we ignore her, and move to enforcing her treatment with the health care team, reminding them that insurance will not reimburse if the patient is not out the door by a certain hour, and that there will be penalties if too many of these patients are readmitted within 30 days.